Provider Demographics
NPI:1902847254
Name:MITCHELL, JANNINE JUENGST (DO)
Entity Type:Individual
Prefix:
First Name:JANNINE
Middle Name:JUENGST
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JANNINE
Other - Middle Name:
Other - Last Name:JUENGST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:350 ENGLE ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1808
Mailing Address - Country:US
Mailing Address - Phone:201-894-3480
Mailing Address - Fax:201-894-5244
Practice Address - Street 1:350 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-894-3480
Practice Address - Fax:201-894-5244
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB0650582085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01985675Medicaid
NY620271Medicare ID - Type Unspecified
NY01985675Medicaid